This Angel is pissed off. I'm Nurse Anne and I work on large general medical ward in the NHS. These are the wards with the most issues surrounding nursing care. The problems are mostly down to intentional understaffing by hospital chiefs that result in a lack of real nurses on the wards.
"The martyr sacrifices themselves entirely in vain. Or rather not in vain, for they merely make the selfish more selfish, the lazy more lazy and the narrow more narrow"-Florence Nightengale

Tuesday, 9 February 2010

An article about the Kids from The Sunday Times.

This article is better than the usual rubbish that we get about nurses. But the headline pisses me off;

They did hit on a lot of good points. Then they fucked it all up by implying that nurses brought novices into the hospital to avoid hands on care. Nurse have no control over hiring, firing, staffing matrixs, or skill mix of ward staff at any given time.

It is true that our hospitals hire people off the street and throw them onto a ward dressed in a nurse's uniform. They are not even training them to be health care assistants anymore.

These people are thrown right onto a ward instead of trained and experienced staff. Absolutely.

The problem I have with the article is the headline really.

"Novices do Nurse's job"

Oh no they are not. They are incapable of doing a nurse's job. They are there on the ward. They may wash patients and make beds if they feel like it. But these things are a far cry from an accurate description of a real nurse's job.

If I am working on a ward as a nurse and the only other staff I have with me are two or three apprentices/care assistants then there is ONE nurse on duty. This article makes out that it is the nurses who are wanting to dump all this work onto the novices and that really leaves a bitter taste in my mouth. The lone nurse simply cannot attend to everything by herself. She knows what needs to be done, she knows what the consequences are. She starts out doing the things that only she can do (this is the stuff that makes a huge impact on patient survival) and she delegates the easy stuff to the novices. There is no other way to do things if you are the only nurse.

As the only nurse I am on my own with all the:

Medications (40 minutes out of every hour of my time for much of the day)
Drips/calculations and monitoring
NG tubes,
Diagnostic tests organisation and preparation
admissions
discharges (complicated and time consuming)
communication with doctors, physios, pharmacy, path lab, specialists (they all go through the nurse rather than talk to eachother)
assessments to avoid "failure to rescue"
wound care
Peg feeds (I have never seen a care assistant change any kind of a drip bag)
suction/trach care
02 delivery and management
post procedure management and care
communication with family members (I cannot get 2 minutes straight free of this to see my patients)
specialing the critically ill patient but not leaving that bedside except to grab supplies and fast bleep the reg.
documenting every single thing that has been ordered for or is happening with every patient
managing and implementing blood transfusions
pressure area care

The novices don't even really know what any of that stuff is. I singlehandedly have to stay on top of all that for 20 people whilst getting interrupted literally every two minutes. When the heck can I do a bedbath? I should be doing it for assessment reasons but something has got to give.

And in addition to all that I need to do basic care so I can see my patients general condition and bring any problems to the attention of the doctor. But certain aspects of basic care are about the only things that novices can help me with. I need to beg the novices to please clean and turn my patients when I am tied up with blood transfusions and doctors rounds. I need to be apologetic towards them for not doing it myself. Everyone just thinks that the nurse wants to dump the basics onto the kids rather than get her hands dirty. Nurses will sometimes abandon things that should not be abandoned in order to assist the apprentices with basic care, trying to prove that she is not "too posh to wash". Then blood transfusion reactions do not get picked up quickly enough.

Recently I was 2 hours into my shift and still hadn't even seen most of my patients at all. One of them took a turn for the worst and was dying before our eyes. I was tied up with that, trying to ring his family to come in. After that was over I made a series of attempts to check on my other patients. Notice I said attempts. Everytime I headed down the ward, phone calls came in and I had to backtrack to the phone. Their drips were empty, dressings were on the floor, cannulas were tissued, catheters were pulled out, people were in retention. The apprentices were on the ward, but they don't get involved in that stuff. They just come to tell me it needs to be done.

Finally after an hour of fighting, I got to the bedside of my first patient out of 20 who looked like she has been cooking a nice hospital acquired chest infection or had possibly aspirated. She was laying flat and sounding pretty bad chest wise. The apprentices would have bed bathed her and left her flat. God knows what they fed her but I doubt it was pureed enough. Her oxygen sats were low, 72% and her only past medical history is dementia. I had just put the 02 on her face and sat her upright. I needed to get some obs, could tell she was pyrexic. She isn't on antibiotics as she originally was admitted for a collapse ? CVA. She hasn't seen a doctor since 9AM Monday morning. It is 4PM on Tuesday. I think I need to get her seen.

Smack in the middle of this two apprentices come into the room. "Anna, there is a phone call at the station for you, it sounds urgent. The ward clerk told us to come and get you". Once we had a good but very part time ward clerk but she is away and has been replaced with shite.

I left my patient and walked all the way back to the nurse's station. It was ambulance control. They wanted the birthdate of a patient they had transferred out that morning.

Does anyone want to tell me why the ward clerk or the apprentices could not look through the discharge book or the notes and give the birthdate out to ambulance control?

This kind of shit happens every time I make an attempt to see a patient. All I am doing is backtracking to the phone, and praying that my patients are okay in the hands of the apprentices.

No. The novices are not helping the nurses or doing a nurse's job. We work for them I think.

A man who commented on The Times article wrote this:

As for the DofH quoting a rise in qualified nurses since 2007 of 8,563; it means nothing if they are passing their responsibilities to healthcare assistants. The increase in nurse numbers is just adding insult to injury.

Those DoH stats are a lie. The few RN's on the ward are left with no choice but to delegate because the tasks that only they can do are overwhelming. And it isn't the paperwork, unless you count the ten forms I have to fill in 20 times an hour to obtain life saving drugs ordered by a doctor. The rest of the paperwork gets completely blown off to the point that we get in trouble over it.

When the apprentices and care assistants are pissing and moaning and whining about being ordered to do bed baths on their own you have to remember this: These kids have absolutely no idea about what the nurse has on her shoulders, nor do they understand how complex and time consuming it all is, nor do they understand the consequences of her not delegating tasks to the untrained staff. It is the mere simple minds who look at this situation and say "the nurse doesn't want to get her hands dirty"

14 comments:

Anonymous
said...

This from a friend in a California hospital....

Critical Care Nurses:

On 2/11/10, the CNO will be presenting a comprehensive response on staffing to our Professional Practice Committee (PPC). On 11/3/09, our PPC met with her and gave her a detailed staffing proposal for all units in the hospital to provide for adequate meal and break relief and staffing to address various acuity issues. Attached is the staffing proposal. Here it is pasted below, with our proposal for additional Critical Care staffing below:

The purpose of this agreement is to ensure that safe staffing standards and levels are maintained at all times including during RNs' meals and breaks and that RNs are provided with 75 minutes of break relief and sufficient time for patient handoff during a 12-hour work shift (or 60 minutes during an 8-hour shift). The following pages outline minimum staffing needed, by department, to ensure staffing for meals and breaks. The CNA PPC and UCSD Nursing Administration shall meet on a regular basis to assess the implementation and progress of adequate and safe staffing for each unit. In addition, the following should be observed and implemented:

1. Break nurses and charge nurses shall not have a patient assignment and shall not be 'in the count'

3. Break nurses should not be given patient assignments, floated to other units, or called off

4. Departments should utilize the break nurse for ALL 75 minutes of meals and breaks (including the 15 minute breaks)

5. Handoff report time shall be built into the schedule for meals and breaks in each unit, is considered work time, and shall be provided before the beginning and after the end of each meal and rest period to assure continuity of care

My cousin, a specialist cardiac nurse, moved to California about five years ago and she loves it. If you are still think of moving, and I would if I were you, could be worth a look. When her mother died quite suddenly and she had to come home, on her return the hospital had raised the money to cover her expenses and salary. She was really touched at their consideration. Can't imagine it here though!

Don't move to the South, Anne! Please don't move down here! It's not as awful as the UK, but there are no protections in place for nurses here - and the powers that be want to keep it that way! Stay WAY north of the Mason-Dixon line!

how did you feel Anne when crippen told you on his blog comments sectios not to be so emmotive? i have been told the same thing a few times by doctors. Dont wear heart on my sleeve, dont let emotions get in the way of the science ect.

Anne please fetch me my anti-emetic (presses buzzer repeatedly and tells relative) as I have just read the following in yet another damn medical induction. It appears that we are all in the wrong...

"It is important to be aware of customer expectations, which may be either too low or too high. Often complaints arise when a customer is promised something that is not fulfilled. The complaint may be along the line of 'the nurse said she was coming back, but was gone for an hour'. We therefore need to make sure that we can manage customers' expectations."

We don't tend to the sick and infirm. We don't have a vocation. We are mere customer servants. It really does break my heart. So so sad.

My girl was previosly in hospital on a medical ward. Her mind is not so good. She wa released on Tuesday. I do not know shat she was infor but she had pain. She ow has sores on her bum. Is this why she was infor. er care was good although she et nothing. thanks for all your hekp I realise she is dificlt, but she cant help this. I have read inyour blog thing that we have unreaistic expectations that she would be liooked after. Is ghis true?Ted.

Nice to hear from you. I am sure your girl is not difficult. When people are ill they need help. That is not being "difficult".

Honestly we do understand when people have problems with memory etc when they are sick. This is normal. Medical patients often have difficulties that way. I will be the exact same way some day. So will my children when they are ill and/or elderly. Everyone deserves to be cared for and cared for well when they are sick and unable to care for themselves.

I am really really sorry to hear that she has sores now. That is something that no patient should ever have to deal with. This is why I do not like medical wards.

I think we do look after people to a reasonable standard most of the time but a severe lack of staff does make it difficult to get everything done for everyone at all times and this does lead to things like sores and delays in treatment. Some days are better than others.

And of course there are crappy nurses as well. I think most of them are good and are working in impossible conditions. It's always hard to say what the situation was because the staff does not really communicate well with the patients and the families.

We just fly from one thing to the next. We are in a hurry and do forget that for most people being in hospital is like being on a competely different planet where nothing makes sense.

Working in the ICU in the UK I would dearly love to have that sort of backup. Just last week we were unable to transfer a patient to another ICU because we did not have enough spare staff to make a transfer team. As for covering breaks, normally we have to double up which means no 1 to 1 care to allow staff to eat. When I am in charge it means I get no break in the 14 or so hours I am at work in order to make sure that most of the other RNs do get a break. I often wonder why on earth I came back to the UK.

In an atmosphere if universal deceit telling the truth is a revolutionary act. George Orwell.

Why has Nursing Care Deteriorated

Good nurses are failing every day to provide their patients with a decent standard of care. You want to know what has happened? Read this book and understand that similiar things have happened in the UK. Similiar causes, similiar consequences. And remember this. The failings in care have nothing to do with educated nurses or nurses who don't care. We need more well educated nurses on the wards rather than intentional short staffing by management.

About Me

I am a university educated registered nurse. We had a hell of a lot of hands on practice as well as our academic courses. The only people who say that you don't need a brain or an education to be an RN are the people who do not have any direct experience of nursing in acute care on today's wards. I have yet to meet a nurse who thinks that she is above providing basic care. I work with nurses who are completely unable to provide basic care due to ward conditions.
I have lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for nearly 15 years. I never used to use foul language until working on the wards got to me. It's a mess everywhere, not just the NHS.
Hospital management is slashing the numbers of staff on the ward whilst filling us up with more patients than we can handle... patients who are increasingly frail. After an 8-14 hour shift without stopping once we have still barely scratched the surface of being able to do what we need to do for our patients.

Quotes of Interest. Education of Nurses.

Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."...Journal of advanced nursing 2007

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level.

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level.

Registered Nurse Staffing Ratios

International Council of Nurses Fact Sheet:

In a given unit the optimal workload for a registered nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission.

A workload of 8 patients versus 4 was associated with a 31% increase in mortality. (In the NHS RN's each have anywhere from 10-35 patients per RN. It doesn't need to be this way..Anne)

Registered Nurses in NHS hospitals usually have between 10 and 30+ patients each on general wards.

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications

•Lower levels of hospital registered nurse staffing are associated with more adverse outcomes such as Pneumonia, pressure sores and death.
•Patients have higher acuity, yet the skill levels of the nursing staff have declined as hospitals replace RN's with untrained carers.
•Higher acuity patients and the added responsibilities that come with them increase the registered nurse workload.
•Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000.
•Hiring more RNs does not decrease profits. (Hospital bosses don't understand this. They think that they will save money by shedding real nurses in favour of carers and assistants. The damage done to the patients as a result of this costs more moneyi.e expensive deaths, complications,and lawsuits, and complaints....Anne)

Disclaimer

I know I swear too much. I am truly very sorry if you are offended. Please do not visit my blog if foul language upsets you. I want to help people. That is why I started this blog and that is why I became a Nurse. I won't run away from Nursing just yet. I want to stick around and make things better. I don't want the nurses caring for me when I am sick working in the same conditions that I am. Of course this is all just a figmant of my imagination anyway and I am not even in this reality. Or am I?Any opinions expressed in my posts are mine and mine alone and do not represent the viewpoint of the NHS, the RCN, God, or anyone else.